Guide to Assessing Psychosocial Yellow Flags
in Acute Low Back Pain:
Risk Factors for Long-Term Disability and Work
Factors for Long-Term Disability and Work Loss
This guide is to be used in
conjunction with the New Zealand Acute Low Back Pain Guide. It
provides an overview of risk factors for long-term disability and work
loss, and an outline of methods to assess these. Identification of
those At Risk should lead to appropriate early management targeted
towards the prevention of chronic pain and disability.
This Guide Aims to Do
This guide complements the New Zealand
Acute Low Back Pain Guide and is intended for use in conjunction with
it. This guide describes Yellow Flags; psychosocial
factors that are likely to increase the risk of an individual with
acute low back pain developing prolonged pain and disability causing
work loss, and associated loss of quality of life. It aims to:
- provide a method of screening for
- provide a systematic approach to
assessing psychosocial factors
- suggest strategies for better
management of those with acute low back pain who have Yellow
Flags indicating increased risks of chronicity.
This guide is not intended to be a
rigid prescription and will permit flexibility and choice, allowing
the exercise of good clinical judgement according to the particular
circumstances of the patient. The management suggestions outlined in
this document are based on the best available evidence to date.
are Psychosocial Yellow Flags?
Yellow Flags are factors
that increase the risk of developing, or perpetuating long-term
disability and work loss associated with low back pain.
Psychosocial Yellow Flags
are similar to the Red Flags in the New Zealand Acute Low
Back Pain Guide. Psychosocial factors are explained in more detail in
Yellow and Red Flags can be thought of
in this way:
Identification of risk factors should
lead to appropriate intervention. Red Flags should lead to appropriate
medical intervention; Yellow Flags to appropriate cognitive and
- Yellow Flags = psychosocial risk
- Red Flags = physical risk factors
The significance of a particular
factor is relative. Immediate notice should be taken if an important
Red Flag is present, and consideration given to an appropriate
response. The same is true for the Yellow Flags.
Assessing the presence of Yellow Flags
should produce two key outcomes:
- a decision as to whether more
detailed assessment is needed
- identification of any salient
factors that can become the subject of specific intervention, thus
saving time and helping to concentrate the use of resources
Red and Yellow Flags are not exclusive
- an individual patient may require intervention in both areas
is there a Need for Psychosocial Yellow Flags for Back Pain Problems?
Low back pain problems, especially
when they are long-term or chronic, are common in our society and
produce extensive human suffering. New Zealand has experienced a
steady rise in the number of people who leave the work force with back
pain. It is of concern that there is an increased proportion who do
not recover normal function and activity for longer and longer
The research literature on risk
factors for long-term work disability is inconsistent or lacking for
many chronic painful conditions, except low back pain, which has
received a great deal of attention and empirical research over the
last 5 years. Most of the known risk factors are psychosocial, which
implies the possibility of appropriate intervention, especially where
specific individuals are recognised as being At Risk.
Who is At Risk?
individual may be considered At Risk if they have a clinical
presentation that includes one or more very strong indicators of risk,
or several less important factors that might be cumulative.
Definitions of primary,
secondary and tertiary prevention
It has been concluded
that efforts at every stage can be made towards prevention of
long-term disability associated with low back pain, including work
- Primary prevention:
- elimination or minimisation of
risks to health or well-being. It is an attempt to determine factors
that cause disabling low back disability and then create programmes
to prevent these situations from ever occurring.
- Secondary prevention:
- alleviation of the symptoms of ill
health or injury, minimising residual disability and eliminating, or
at least minimising, factors that may cause recurrence. It is an
attempt to maximise recovery once the condition has occurred and
then prevent its recurrence. Secondary prevention emphasises the
prevention of excess pain behaviour, the sick role, inactivity
syndromes, re-injury, recurrences, complications, psychosocial
sequelae, long-term disability and work loss.
- Tertiary prevention:
- rehabilitation of those with
disabilities to as full function as possible and modification of the
workplace to accommodate any residual disability. It is applied
after the patient has become disabled. The goal is to return to
function and patient acceptance of residual impairment(s); this may
in some instances require work site modification.
The focus of this guide is on
prevention aims to prevent:
- excess pain behaviour, sick role,
- re-injury, recurrences
- complications, psychosocial
sequelae, long-term disability, work loss
Before proceeding to assess Yellow
Flags, treatment providers need to carefully differentiate between the
presentations of acute, recurrent and chronic back pain, since the
risk factors for developing long-term problems may differ even though
there is considerable overlap.
- Acute low back problems:
- activity intolerance due to lower
back or back and leg symptoms lasting less than 3 months.
- Recurrent low back problems:
- episodes of acute low back problems
lasting less than 3 months but recurring after a period of time
without low back symptoms sufficient to restrict activity or
- Chronic low back problems:
- activity intolerance due to lower
back or back and leg symptoms lasting more than 3 months.
of Assessing Psychosocial Yellow Flags
The three main consequences of back
- disability, limitation in function
including activities of daily living
- reduced productive activity,
including work loss
prevent the development of chronic pain through physiological or
pharmacological interventions in the acute phase have been relatively
ineffective. Research to date can be summarised by stating that
inadequate control of acute (nociceptive) pain may increase the risk
of chronic pain.
loss of function, reduced activity, distress and low mood is an
important, yet distinct goal. These factors are critical to a persons
quality of life and general well-being. It has been repeatedly
demonstrated that these factors can be modified in patients with
chronic back pain. It is therefore strongly suggested that treatment
providers must prevent any tendency for significant withdrawal from
activity being established in any acute episode.
probability of successfully returning to work in the early stages of
an acute episode depends on the quality of management, as described in
this guide. If the episode goes on longer the probability of returning
to work reduces. The likelihood of return to any work is even smaller
if the person loses their employment, and has to re-enter the job
disability and work loss are associated with profound suffering and
negative effects on patients, their families and society. Once
established they are difficult to undo. Current evidence indicates
that to be effective, preventive strategies must be initiated at a
much earlier stage than was previously thought. Enabling people to
keep active in order to maintain work skills and relationships is an
Most of the known risk factors for
long-term disability, inactivity and work loss are psychosocial.
Therefore, the key goal is to identify Yellow Flags that increase the
risk of these problems developing. Health professionals can
subsequently target effective early management to prevent onset of
Please note that it is important to
avoid pejorative labelling of patients with Yellow Flags (see
Appendix 2) as this will have a
negative impact on management. Their use is intended to encourage
treatment providers to prevent the onset of long-term problems in At
Risk patients by interventions appropriate to the underlying cause.
to Judge if a Person is at Risk
A person may be At Risk if:
There is good agreement that the
following factors are important and consistently predict poor outcomes:
- there is a cluster of a few very
- there is a group of several less
important factors that combine cumulatively
Suggested questions (to be phrased in
treatment providers own words):
- presence of a belief that back
pain is harmful or potentially severely disabling
- fear-avoidance behaviour (avoiding
a movement or activity due to misplaced anticipation of pain) and
reduced activity levels
- tendency to low mood and
withdrawal from social interaction
- an expectation that passive
treatments rather than active participation will help
- Have you had time off work in the
past with back pain?
- What do you understand is the
cause of your back pain?
- What are you expecting will help
- How is your employer responding to
your back pain? Your co-workers? Your family?
- What are you doing to cope with
- Do you think that you will return
to work? When?
to Assess Psychosocial Yellow Flags
A detailed discussion of methods to
identify Yellow Flags is given in Appendix
Clinical assessment of Yellow Flags
involves judgements about the relative importance of factors for the
individual. Table 2 lists factors under the headings of Attitudes and
Beliefs about Back Pain, Behaviours, Compensation Issues, Diagnosis and
Treatment, Emotions, Family and Work.
- If large numbers need to be
screened quickly there is little choice but to use a questionnaire.
Problems may arise with managing the potentially large number of At
Risk people identified. It is necessary to minimise the number of
false positives (those the screening test identifies who are not
actually At Risk).
- If the goal is the most accurate
identification of Yellow Flags prior to intervention, clinical
assessment is preferred. Suitably skilled clinicians with adequate
time must be available.
- The two-stage approach shown in
Figure 2 is recommended if the numbers are large and skilled
assessment staff are in short supply. The questionnaire can be used
to screen for those needing further assessment. In this instance,
the number of false negatives (those who have risk factors, but are
missed by the screening test) must be minimised.
- To use the
- To conduct a clinical assessment
for Acute Back Pain, see Table 1.
These headings have been used for
convenience in an attempt to make the job easier. They are presented
in alphabetical order since it is not possible to rank their
importance. However, within each category the factors are listed with
the most important at the top.
Please note, clinical assessment may
be supplemented with the questionnaire method (ie the Acute Low Back
Pain Screening Questionnaire in Table 1) if that has not already been
done. In addition, treatment providers familiar with the
administration and interpretation of other pain-specific psychometric
measures and assessment tools (such as the Pain Drawing, the
Multidimensional Pain Inventory, etc) may choose to employ them.
Become familiar with the potential disadvantages of each method to
minimise any potential adverse effects.
The list of factors provided here is
not exhaustive and for a particular individual the order of importance
may vary. A word of caution: some factors may appear to be mutually
exclusive, but are not in fact. For example, partners can alternate
from being socially punitive (ignoring the problem or expressing
frustration about it) to being over-protective in a well intentioned
way (and inadvertently encouraging extended rest and withdrawal from
activity, or excessive treatment seeking). In other words, both
factors may be pertinent.
here to print the algorithm and quick reference guide for off-line
Assessment of Psychosocial Yellow Flags
These headings (Attitudes and Beliefs
about Back Pain, Behaviours, Compensation Issues, Diagnosis and
Treatment, Emotions, Family and Work) have been used for convenience
in an attempt to make the job easier. They are presented in
alphabetical order since it is not possible to neatly rank their
importance. However, within each category the factors are listed with
the most important at the top of the list.
Clinical assessment of Psychosocial Yellow Flags
and Beliefs about Back Pain
Belief that pain is harmful or disabling resulting in fear-avoidance
behaviour, eg, the development of guarding and fear of movement
- Belief that all pain must be
abolished before attempting to return to work or normal activity
- Expectation of increased pain with
activity or work, lack of ability to predict capability
- Catastrophising, thinking the
worst, misinterpreting bodily symptoms
- Belief that pain is uncontrollable
- Passive attitude to rehabilitation
- Use of extended rest,
- Reduced activity level with
significant withdrawal from activities of daily living
- Irregular participation or poor
compliance with physical exercise, tendency for activities to be in
a boom-bust cycle
- Avoidance of normal activity and
progressive substitution of lifestyle away from productive activity
- Report of extremely high intensity
of pain, eg, above 10, on a 0 to 10 Visual Analogue Scale
- Excessive reliance on use of aids
- Sleep quality reduced since onset
of back pain
- High intake of alcohol or other
substances (possibly as self-medication), with an increase since
onset of back pain
- Lack of financial incentive to
return to work
- Delay in accessing income support
and treatment cost, disputes over eligibility
- History of claim(s) due to other
injuries or pain problems
- History of extended time off work
due to injury or other pain problem (eg more than 12 weeks)
- History of previous back pain,
with a previous claim(s) and time off work
- Previous experience of ineffective
case management (eg absence of interest, perception of being treated
punitively) Diagnosis and Treatment
- Health professional sanctioning
disability, not providing interventions that will improve function
- Experience of conflicting
diagnoses or explanations for back pain, resulting in confusion
- Diagnostic language leading to
catastrophising and fear (eg fear of ending up in a wheelchair)
- Dramatisation of back pain by
health professional producing dependency on treatments, and
continuation of passive treatment
- Number of times visited health
professional in last year (excluding the present episode of back
- Expectation of a techno-fix,
eg, requests to treat as if body were a machine
- Lack of satisfaction with previous
treatment for back pain
- Advice to withdraw from job
- Fear of increased pain with
activity or work
- Depression (especially long-term
low mood), loss of sense of enjoyment
- More irritable than usual
- Anxiety about and heightened
awareness of body sensations (includes sympathetic nervous system
- Feeling under stress and unable to
maintain sense of control
- Presence of social anxiety or
disinterested in social activity
- Feeling useless and not needed
- Over-protective partner/spouse,
emphasising fear of harm or encouraging catastrophising (usually
- Solicitous behaviour from spouse
(eg taking over tasks)
- Socially punitive responses from
spouse (eg ignoring, expressing frustration)
- Extent to which family members
support any attempt to return to work
- Lack of support person to talk to
- History of manual work, notably
from the following occupational groups:
- fishing, forestry and farming
construction, including carpenters and builders;
- Work history, including patterns
of frequent job changes, experiencing stress at work, job
dissatisfaction, poor relationships with peers or supervisors, lack
of vocational direction
- Belief that work is harmful; that
it will do damage or be dangerous
- Unsupportive or unhappy current
- Low educational background, low
- Job involves significant
bio-mechanical demands, such as lifting, manual handling heavy
items, extended sitting, extended standing, driving, vibration,
maintenance of constrained or sustained postures, inflexible work
schedule preventing appropriate breaks
- Job involves shift work or working
- Minimal availability of selected
duties and graduated return to work pathways, with unsatisfactory
implementation of these
- Negative experience of workplace
management of back pain (eg absence of a reporting system,
discouragement to report, punitive response from supervisors and
- Absence of interest from employer
Remember the key question to bear in
mind while conducting these clinical assessments is What can be
done to help this person experience less distress and disability?
What can be done to help
somebody who is At Risk?
These suggestions are not
intended to be prescriptions, or encouragement to ignore individual
needs. They are intended to assist in the prevention of long-term
disability and work loss.
Suggested steps to better
early behavioural management of low back pain problems
- Provide a positive expectation
that the individual will return to work and normal activity.
Organise for a regular expression of interest from the employer. If
the problem persists beyond 2 to 4 weeks, provide a reality
based warning of what is going to be the likely outcome (eg
loss of job, having to start from square one, the need to begin
reactivation from a point of reduced fitness, etc).
- Be directive in scheduling regular
reviews of progress. When conducting these reviews shift the focus
from the symptom (pain) to function (level of activity). Instead of
asking how much do you hurt?, ask what have you
been doing?. Maintain an interest in improvements, no matter
how small. If another health professional is involved in treatment
or management, specify a date for a progress report at the time of
referral. Delays will be disabling.
- Keep the individual active and at
work if at all possible, even for a small part of the day. This will
help to maintain work habits and work relationships. Consider
reasonable requests for selected duties and modifications to the
work place. After 4 to 6 weeks, if there has been little
improvement, review vocational options, job satisfaction, any
barriers to return to work, including psychosocial distress. Once
barriers to return to work have been identified, these need to be
targeted and managed appropriately. Job dissatisfaction and distress
cannot be treated with a physical modality.
- Acknowledge difficulties with
activities of daily living, but avoid making the assumption that
these indicate all activity or any work must be avoided.
- Help to maintain positive
cooperation between the individual, an employer, the compensation
system, and health professionals. Encourage collaboration wherever
possible. Inadvertent support for a collusion between them
and us can be damaging to progress.
- Make a concerted effort to
communicate that having more time off work will reduce the
likelihood of a successful return to work. In fact, longer periods
off work result in reduced probability of ever returning to work. At
the 6 week point consider suggesting vocational redirection, job
changes, the use of knights move approaches to
return to work (same employer, different job).
- Be alert for the presence of
individual beliefs that he/she should stay off work until treatment
has provided a total cure; watch out for expectations of
- Promote self-management and
self-responsibility. Encourage the development of self-efficacy to
return to work. Be aware that developing self-efficacy will depend
on incentives and feedback from treatment providers and others. If
recovery only requires development of a skill such as adopting a new
posture, then it is not likely to be affected by incentives and
feedback. However, if recovery requires the need to overcome an
aversive stimulus such as fear of movement (kinesiophobia) then it
will be readily affected by incentives and feedback.
- Be prepared to ask for a second
opinion, provided it does not result in a long and disabling delay.
Use this option especially if it may help clarify that further
diagnostic work up is unnecessary. Be prepared to say I dont
know rather than provide elaborate explanations based on
- Avoid confusing the report of
symptoms with the presence of emotional distress. Distressed people
seek more help, and have been shown to be more likely to receive
ongoing medical intervention. Exclusive focus on symptom control is
not likely to be successful if emotional distress is not dealt with.
- Avoid suggesting (even
inadvertently) that the person from a regular job may be able to
work at home, or in their own business because it will be under
their own control. This message, in effect, is to allow pain to
become the reinforcer for activity - producing a deactivation
syndrome with all the negative consequences. Self employment nearly
always involves more hard work.
- Encourage people to recognise,
from the earliest point, that pain can be controlled and managed so
that a normal, active or working life can be maintained. Provide
encouragement for all well behaviours - including
alternative ways of performing tasks, and focusing on transferable
- If barriers to return to work are
identified and the problem is too complex to manage, referral to a
multidisciplinary team as described in the New Zealand Acute Low
Back Pain Guide is recommended.
are the Consequences of Missing Psychosocial Yellow Flags?
Under-identifying At Risk patients may
result in inadvertently reinforcing factors that are disabling.
Failure to note that specific patients strongly believe that movement
will be harmful may result in them experiencing the negative effects
of extended inactivity. These include withdrawal from social,
vocational and recreational activities.
Cognitive and behavioural factors can
produce important physiological consequences, the most common of which
is muscle wasting.
Since the number of earlier treatments
and length of the problem can themselves become risk factors, most
people should be identified the second time they seek care.
Consistently missing the presence of Yellow Flags can be harmful and
usually contributes to the development of chronicity.
- There may be significant adverse
consequences if these factors are overlooked.
are the Consequences of Over-identifying Psychosocial Yellow Flags?
Over-identification has the potential
to waste some resources. However, this is readily outweighed by the
large benefit from helping to prevent even one person developing a
long-term chronic back problem.
Some treatment providers may wonder if
identifying psychosocial risk factors, and subsequently applying
suitable cognitive and behavioural management can produce adverse
effects. Certainly if the presence of psychosocial risk factors is
misinterpreted to mean that the problem should be translated from a
physical to a psychological one, there is a danger of the patient
losing confidence in themselves and their treatment provider(s).
- There are unlikely to be adverse
consequences from the over-identification of Yellow Flags.
The presence of risk factors should
alert the treatment provider to the possibility of long-term problems
and the need to prevent their development. Specialised psychological
referrals should only be required for those with psychopathology (such
as depression, anxiety, substance abuse, etc), or for those who fail
to respond to appropriate management.